Angina pectoris, commonly referred to as “angina”, is chest pain or discomfort that occurs when the heart muscle does not receive enough blood flow and oxygen. It is often described as tightness, pressure, squeezing, or crushing pain in the chest. Angina is a symptom of coronary artery disease (CAD), which is caused by plaque buildup and narrowing of the coronary arteries.There are three main types of angina:
- Stable angina: Occurs during increased activity, emotional stress, exposure to cold temperatures, or after eating heavy meals. Pain is relieved by rest or nitroglycerin medication. This is the most common type.
- Unstable angina: Chest pain that changes in frequency, duration, intensity, or triggers. It can occur at rest.
- Variant/Prinzmetal angina: Caused by coronary artery spasm. Pain can occur at rest or while sleeping.
For nurses and nursing students preparing for the NCLEX exam, having a strong understanding of the pathophysiology, signs and symptoms, diagnosis, and treatments for angina is essential. This article provides a comprehensive nursing guide to caring for patients with different types of angina.
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Angina Pathophysiology
Angina occurs when there is an imbalance between the heart’s oxygen demand and the oxygen supplied by the coronary arteries. When the demand exceeds supply, ischemia (lack of blood flow) occurs, causing chest pain.
The most common cause is atherosclerotic plaque accumulation over time. Plaque narrows the coronary arteries (the vessels that supply oxygenated blood to the heart muscle), limiting blood flow. Any increased oxygen demand, like during exercise, emotions, or cold exposure cannot be met, resulting in angina pain.With unstable angina, plaques become unstable and rupture, causing platelets to form blood clots at the rupture site.
This can further block the artery.Variant angina is caused by coronary artery spasm, which abruptly reduces blood flow despite no plaque rupture or clotting. The exact mechanism is unclear but it may relate to endothelial dysfunction.
Signs and Symptoms
Typical angina symptoms include:
- Chest pain described as tightness, pressure, squeezing, crushing, burning or aching sensation
- Pain that moves to the shoulders, arms, neck, back, or jaw
- Shortness of breath
- Nausea
- Sweating
- Lightheadedness
The chest pain often lasts between 1-15 minutes.With stable angina, symptoms occur during physical exertion or stress and resolve with rest.Unstable angina is considered an emergency as symptoms can occur suddenly at rest, indicating high risk for myocardial infarction.
Additional symptoms may include palpitations, fatigue, and weakness.Variant angina pain also comes on at rest but symptoms may happen in clusters at night.
Diagnosis
To diagnose angina, physicians take a full history looking closely at the chest pain characteristics, triggers, relieving factors, and associated symptoms. Diagnostic tests aid in confirming angina and evaluating the extent of CAD.
Medical History
Doctors assess:
- Chest pain onset, location, quality, severity, duration
- Triggers – activity, cold, emotions
- Relieving factors – rest, nitroglycerin
- Risk factors – family history, smoking, obesity, hypertension
- Existing diagnoses – previous heart attack, heart failure, arrhythmias
Physical Exam
The physical exam evaluates for:
- Irregular heart sounds, murmurs, rhythm
- Signs of heart failure – edema, jugular vein distension
- Diminished peripheral pulses
Diagnostic Tests
- Electrocardiogram (ECG): Looks for signs of ischemia (inverted T waves) or prior infarction (Q waves). Can show changes during an angina episode.
- Exercise stress test: Monitors ECG while patient exercises on treadmill. Ischemic ECG changes confirm angina diagnosis.
- Echocardiogram: Evaluates heart structure and function. Can identify prior infarction.
- Cardiac catheterization: Injects contrast dye to visualize coronary arteries for blockages using angiograms. Can also measure blood flow.
- Blood tests: Evaluate cardiac enzyme levels to rule out heart attack. Also assess cholesterol levels.
Angina Treatments
The main goals of angina treatment are to:
- Improve blood flow to the heart
- Decrease oxygen demand
- Prevent future cardiac events
This involves medications and lifestyle changes. Procedures or surgery may be done for refractory cases.
Medications
Several medication classes are used:
Nitrates
Most common is nitroglycerin, available as short-acting tablets, sprays, or patches. Nitrates relax blood vessels to improve flow. Used to treat acute angina attacks and prevent episodes.
Beta blockers
Help decrease heart rate and blood pressure to reduce oxygen demand. Examples: metoprolol, carvedilol.
Calcium channel blockers
Relax coronary arteries to increase blood flow. Also used to lower blood pressure. Examples: amlodipine, diltiazem.
Antiplatelets
Like aspirin. Help prevent blood clot formation. Important for reducing risk of heart attack and stroke.
Statins
Decrease LDL cholesterol levels in blood to prevent further plaque buildup. Examples: atorvastatin, rosuvastatin.
Ranolazine
Used in combination therapy for refractory chronic angina unresponsive to other medications. Exact mechanism uncertain but likely improves blood flow.
Lifestyle Changes
Lifestyle changes that reduce cardiac workload are key:
- Smoking cessation
- Weight loss if overweight
- Healthy diet low in saturated fats
- Regular aerobic activity
- Stress management
- Avoiding triggers like cold temperatures
Procedures and Surgery
For severe refractory angina, procedures to improve blood flow include:
- Angioplasty and stenting
- Coronary artery bypass grafting (CABG)
These aim to bypass or physically open critically narrowed arteries.
Nursing Care and Considerations
Nurses play a pivotal role in caring for patients with angina. Priorities include patient education, administering medications, monitoring symptoms, and ensuring patient safety.
Patient Education
Education should cover:
- Disease process
- Medication purpose and administration
- Warning signs to promptly report
- Risk factor modification
- Individualized trigger avoidance
Reinforce calling 911 for unrelieved chest pain lasting >15 minutes.
Review nitroglycerin administration for acute attacks.
Instruct patients to sit or lie down before taking nitroglycerin to prevent falls from sudden blood pressure drops.
Medication Administration
Nurses should:
- Administer medications on time
- Teach patients proper administration
- Monitor for side effects
- Assess medication efficacy and tolerance
With nitrates, monitor for headaches, dizziness, or hypotension.
Symptom Monitoring
Track frequency, duration, and severity of chest pain episodes. Notify physician of any worsening or sudden changes.Check oxygen saturation and lung sounds, as shortness of breath may occur.
Safety and Risk Reduction
Ensure bed rails raised for patients at fall risk from nitrate use.Educate on cardiac risk factor modification for secondary prevention. Encourage smoking cessation, diet changes, activity goals tailored to tolerance, and tips to manage stress.
NCLEX Angina Questions
Let’s review some angina questions commonly seen on the NCLEX:
- A 68-year-old female with a 30-pack-year smoking history comes to the ED reporting chest tightness, rating it 8/10. Symptoms started while gardening and were relieved with rest in 10 minutes. She has a history of type 2 diabetes and hypertension. What type of angina does she most likely have?
A. Unstable angina
B. Variant angina
C. Stable angina
D. Non-cardiac chest pain
Rationale: Her long smoking history and comorbidities indicate high risk for CAD. The pain was triggered by activity and resolved fully with rest in a short period, indicative of stable angina.
- A nurse is caring for a patient who had a stent placed for a 90% LAD artery stenosis. The patient has new-onset angina occurring at rest. Which finding should the nurse recognize as the priority to report?
A. Jugular vein distension
B. Crackles on lung auscultation
C. New T wave inversions on ECG
D. Chest pain unrelieved by nitroglycerin
Rationale: Unrelieved chest pain with rest angina indicates unstable angina or possible infarction. This should be reported urgently as it signifies myocardial ischemia despite revascularization.
- A patient asks the nurse why he has to take multiple medications for his angina. Which response by the nurse is most appropriate?
A. “Each medication works by a different mechanism to prevent chest pain.”
B. “The synergistic effects of the drugs enhance efficacy.”
C. “It’s important we try to identify which one helps you the most.”
D. “Using different drug classes reduces your risk of future cardiac events.”
Rationale: The nurse should educate that multiple drugs targeting different pathways, like nitrates, beta blockers, and statins, help improve blood flow while reducing risk factors and preventing recurrent ischemia or infarction.
Conclusion
Angina requires prompt evaluation and tailored management to relieve symptoms and minimize adverse cardiac outcomes.
As patients’ primary caregivers, nurses need an excellent grasp of assessment findings, diagnostic evaluation, optimal medical therapy, patient education priorities, and safety considerations for optimal outcomes across the angina spectrum. Appropriate nursing interventions can significantly improve function, quality of life, and prognosis.
